PRINTED: 03/20/2018 DEPARTMENT OF HEALTH AND HUMAN

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

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PRINTED: 03/20/2018FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

495105 03/24/2016

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STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

5615 SEMINOLE AVENUELYNCHBURG HLTH & REHAB CNTR

LYNCHBURG, VA 24502

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

An unannounced Medicare/Medicaid standard

survey was conducted on 3/22/16 through

3/24/16. Two complaints were investigated.

Corrections are required for compliance with 42

CFR Part 483, the Federal Long Term Care

requirements. The Life Safety Code

survey/report will follow.

The census in this 180 certified bed facility was

149 at the time of the survey. The survey sample

consisted of 21 current Resident reviews

(Residents # 1 through 21) and three closed

record reviews (Residents # 22 through 24).

F 167

SS=C

RIGHT TO SURVEY RESULTS - READILY

ACCESSIBLE

CFR(s): 483.10(g)(1)

A resident has the right to examine the results of

the most recent survey of the facility conducted by

Federal or State surveyors and any plan of

correction in effect with respect to the facility.

The facility must make the results available for

examination and must post in a place readily

accessible to residents and must post a notice of

their availability.

This REQUIREMENT is not met as evidenced

by:

F 167 4/19/16

Based on observation, staff interview, and

resident interview the facility failed to post notice

of location and ensure readable form and without

devices readily available of the survey results

report.

The statements included are not an

admission and do not constitute

agreement with the alleged deficiencies

herein. The plan of correction is

completed in the compliance of state and

federal regulations as outlined. To remain

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

04/07/2016Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete 3K8I11Event ID: Facility ID: VA0054 If continuation sheet Page 1 of 74

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F 167 Continued From page 1 F 167

The survey result book did not have posted notice

and was observed in small print without devices

to enhance readability.

Findings:

Throughout the survey process conducted

3/22/16 through 3/24/16 general observations

were performed. The most recent survey report

book was located in the main entrance lobby on a

table next to the administrator's office. There was

no evidence of notice as to where the survey

book was located, except for the survey book

itself.

Review of the survey book revealed the print to

be small approximately 10 to 12 font and without

any devices to enhance readability, such as a

magnifying glass.

On 3/24/16 at 8:45 a.m. a certified nursing

assistant (identified as CNA #10) working on the

east wing of the facility was interviewed

concerning the location of the survey book. CNA

#10 verbalized that the book was at the nurses

station and proceeded to look for the survey

book. After not being able to locate the survey

book, CNA #10 verbalized that she thought it

(survey book) was up in the front lobby.

On 3/24/16 at 9:15 a.m. the Resident council

president was interviewed concerning the location

of the survey book. The Resident council

president verbalized that the book might be up

front somewhere. When asked if he (Resident

council president) had ever reviewed the survey

book, the Resident president council verbalized,

no.

in compliance with all federal and state

regulations the center has taken or will

take the actions set forth in the following

plan of correction. The following plan of

correction constitutes the center�s

allegation of compliance. All alleged

deficiencies cited have been or will be

completed by the dates indicated.

F167

1. A notice is posted in the front lobby

that identifies the location of the survey

book. A magnifying page has been

placed inside the survey book cover to

enhance readability.

2. Current facility staff and residents will

be educated regarding notice and location

of the survey book.

3. The front desk receptionist will ensure

that the notice and survey book with

magnifying page is in place daily 5X

weekly X one month and weekly X 2

months. Any issues will be addressed

immediately at the time of identification.

4. Process will be reviewed in QA

committee for two quarters.


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The above finding was brought to the attention of

the Administrator and Director of nursing on

3/24/16 at 10:30 a.m.

No other information was given to the survey

team prior to the exit conference on 3/24/16.

F 241

SS=D

DIGNITY AND RESPECT OF INDIVIDUALITY

CFR(s): 483.15(a)

The facility must promote care for residents in a

manner and in an environment that maintains or

enhances each resident's dignity and respect in

full recognition of his or her individuality.


by:

F 241 4/19/16

Based on observation, and staff interview, the

facility staff failed to promote dignity for three of

24 residents, Resident #9, Resident #7 and

Resident #10.

1. Resident #9's ileostomy bag was not covered

by a privacy bag.

2. Resident #7 was not provided a dignified

dining experience during breakfast in the East

Wing Restorative Dining Room.


dining experience during breakfast in the West

Wing Dining Room.

Findings were:

1. Resident # 9 was originally admitted to the

facility on 02/22/2016 with the following

diagnoses, but not limited to: Critical Illness

F241

1. Resident #9 no longer resides at the

facility. Residents #7 and #10 are

currently being provided a dignified dining

experience. Residents seated at the same

table are served meals at the same time.

2. Current residents� meal preference

location and tray times will be reviewed to

ensure consistency with being able to

serve residents at the same table at the

same time. Adjustments will be made as

indicated.

3. Current facility direct care staff will be

educated regarding a dignified dining

experience to include serving residents

seated at the same table at the same

time. Nursing and Dietary leadership will

observe dining areas daily 5X weekly X

one month then 3X weekly X 2 months to

ensure residents seated at the same table

are being served at the same time. Any


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Myopathy, hypertension, severe protein-calorie

malnutrition (requiring TPN -total parental

nutrition), congestive heart failure, chronic kidney

disease, gastroduodenitis with bleeding, gastritis

with bleeding, ileostomy and COPD (chronic

obstructive pulmonary disease).

The most recent MDS (minimum data set) was

an admission assessment with an ARD

(assessment reference date) of 02/29/2016.

Resident #9 was assessed as having a cognitive

summary score of "08", indicating moderate

impairment with her cognitive status.

Initial tour of the facility was conducted on

03/22/2015 at approximately 10:30 a.m.

Resident #9 was observed lying in bed, supine,

eyes closed, nasal cannula in place. A large

round tube was observed coming out from under

the sheet and down the side of the bed, the tube

entered into a large rectangular container. The

tube and the container contained brown liquid.

The container was not in any type of privacy bag

and was propped up and visible inside of a pink

basin normally used for bed baths.

LPN (licensed practical nurse) # 1 was in the

hallway and was asked to accompany this

surveyor to the room. This surveyor asked what

the tubing coming from under the sheet was.

LPN #1 stated, "That is her rectal tube." LPN #1

was asked why Resident #9 had a rectal tube.

She stated, "She has an ileostomy, the rectal

tube catches what doesn't come out of the

ostomy." LPN #1 asked why the resident had

both a rectal tube and an ileostomy. She stated,

"She has it [feces] coming from both places.

They put in the rectal tube to keep her from

getting any skin breakdown."

issues will be addressed immediately at

the time of identification.




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After reviewing the clinical record, this surveyor

asked LPN #1 to accompany her to Resident #9's

room. LPN #1 stated, "I told you wrong. She

doesn't have a rectal tube. The tube is from her

ileostomy bag." LPN #1 showed the ileostomy

bag to this surveyor. The ostomy bag was open

at the bottom and connected to the tubing which

then connected to the rectangular container. The

container was observed to have been placed

inside of a black privacy bag and remained

propped up in the pink basin. She stated, "This is

how she and her husband had it hooked up at

home and they wanted us to continue it." LPN #1

was asked what the black bag was for. She

stated, "It's a privacy bag, the container should

have been in there."

The above information was discussed during an

end of the day meeting with the administrative

staff on 03/23/2016 at approximately 3:50 p.m.

No further information was obtained prior to the

exit conference on 03/24/2016.


dining experience during breakfast in the East

Wing Restorative Dining Room.

Resident #7 was most recently readmitted to the


diagnoses, but not limited to: Hypoglycemia,

hypertension, type II diabetes mellitus,

Alzheimer's, seizures, psychosis, and anemia.

The most recent MDS (minimum data set) was a

quarterly assessment with an ARD (assessment

reference date) of 03/14/2016. Resident #7 was

assessed as having a cognitive summary score


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of "08", indicating moderate impairment with her

cognitive status.

On 03/23/2016 a breakfast meal observation was

conducted in the East wing restorative dining

room beginning at approximately 7:35 a.m.

There were four tables in the dining room with a

total of nine residents seated around the tables.

Resident #7 was observed sitting at a table with

two other residents. Resident #7 was seated

looking across the table and out of the window.

One of the residents seated at the table was

eating breakfast. Resident #7 and another

resident did not have a tray. There were no staff

members in the room.

At approximately 7:45 a.m., two CNAs (Certified

nursing assistants) entered the room. CNA #2

was asked why all of the residents were not

eating. She stated, "We are waiting on the trays."

CNA #2 was asked if the residents who were not

eating minded watching others eat. She stated,

"They don't mind, they sit and watch the cars go

by outside...I am just in here to deserve [observe]

them...their food is on the second cart." CNA #2

was asked if she was a restorative aid. She

stated, "No, I am just a plain CNA...I am only here

to deserve [observe] them."

Two nurse consultants came down the hall while

this surveyor was standing outside of the dining

room. They were asked why no staff had been in

the room earlier and why all residents had not

been served. The corporate QI (quality

improvement) nurse went into the dining room

and spoke to CNA #2, stating, "Go get her tray

now." The corporate QI nurse stated, "They

know better than that...I have been working on


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this."

Resident #7's tray was served at approximately

8:00 a.m. Resident #7 was asked if she was

hungry, she stated, "I'm always hungry."

The above information was discussed with the

administrative staff during an end of the day

meeting on 03/23/2016 at approximately 3:50

p.m.



3. The facility staff failed to promote a dignified

dining experience for Resident # 10. The

resident sat at a table for approximately 45

minutes while two other residents were served,

and were fed their breakfast.

Resident # 10 in the survey sample, a 78 year-old

female, was originally admitted to the facility on

7/10/14, and most recently readmitted on 2/3/15

with diagnoses that included a history of femoral

neck fracture, hypertension, osteoporosis, anxiety

disorder, dementia, hypokalemia, anemia,

gastroesophageal reflux disease, hyperlipidemia,

generalized muscle weakness, and difficulty

walking. According to the most recent Annual

MDS, with an ARD of 7/13/15, the resident was

assessed under Section C (Cognitive Patterns)

as being severely cognitively impaired, with a

Summary Score of 3 out of 15.

According to the most recent Quarterly MDS, with

an ARD of 3/14/16, the resident was assessed

under Section C (Cognitive Patterns) as having

short and long term memory problems with

severely impaired daily decision making skills.


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At approximately 7:50 a.m. on 3/23/16, an

observation of the breakfast meal in the West

Wing Day Room was started. Resident # 10 was

seated at a table with two other female residents,

one on her right, and the other across the table

from her.

At approximately 7:55 a.m., the resident seated

across from Resident # 10 was served her

breakfast. After the tray was set-up, the

resident's daughter, who was present at the time,

began feeding her. At about 8:20 a.m., the

resident finished her breakfast. Her daughter left

the day room and the resident remained seated

at the table with Resident # 10. When asked

later, CNA # 1 (Certified Nursing Assistant) said

the resident's daughter "...comes in and feeds her

mother almost everyday."

At about 8:25 a.m., the resident seated on

Resident # 10's right was served her breakfast.

After the tray was set-up, the resident was fed by

CNA # 1. At about 8:35 a.m., the resident

finished breakfast. CNA # 1 removed the

resident's tray and the resident remained seated

at the table.

At approximately 8:45 a.m., CNA # 1 brought

Resident # 10's breakfast tray. After the tray was

set-up, CNA # 1 began feeding the resident.

While Resident # 10 was fed breakfast, the

resident on her right and the resident across from

her continued to sit at the table and watch her

eat.

Resident # 10 sat at the table for approximately

45 minutes watching the other two residents eat

while she waited for her breakfast tray.


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The observations were discussed with the

administrative staff during an end of day meeting

at 4:00 p.m. on 3/23/16.

F 271

SS=D

ADMISSION PHYSICIAN ORDERS FOR

IMMEDIATE CARE

CFR(s): 483.20(a)

At the time each resident is admitted, the facility

must have physician orders for the resident's

immediate care.


by:

F 271 4/19/16

Based on staff interview and clinical record

review, the facility staff failed to obtain orders for

the immediate care of a central line for one of 24

residents, Resident #9. Resident #9 was

admitted with a tunneled central line into her

upper left chest. No orders were written at the

time of the admission for the care of the insertion

site.

Findings were:

Resident # 9 was originally admitted to the facility

on 02/22/2016 with the following diagnoses, but

not limited to: Critical Illness Myopathy,

hypertension, severe protein-calorie malnutrition

(requiring TPN -total parental nutrition),

congestive heart failure, chronic kidney disease,

gastroduodenitis with bleeding, gastritis with

bleeding, ileostomy and COPD (chronic




F271

1. Resident #9 no longer resides at the

facility.

2. Current residents with central venous

access devices were reviewed to ensure

physician orders were in place at the time

of admission for immediate care and are

currently active. Corrections were made

immediately as indicated.

3. Licensed nursing staff were educated

by nursing leadership regarding the need

for physician orders at the time of

admission for residents� immediate care.

Licensed nursing staff will ensure orders

are in place at the time of admission for

care of central venous access devices.

Unit managers or designees will review

new admissions daily 5X weekly X 3

months to ensure accuracy of orders. Any






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eyes closed, nasal cannula in place. A large IV

(intravenous bag) was observed attached to an

infusion pump at her bedside, the pump was off.



surveyor to the room..This surveyor asked what

the bag was hanging at the bedside. She stated,

"Her TPN [total parenteral nutrition], it is through

infusing, I am going to take it down."

The clinical record was reviewed on 03/22/2016

beginning at approximately 1:00 p.m. The POS

(Physician order sheet) contained the following

orders: "Normal Saline Flush 10 ml (milliliters)

intravenously one time per day for tunneled

catheter" and "Heparin lock flush 10 units/ml use

5 ml intravenously one time a day for tunneled

catheter." There were also orders for TPN,

different mixtures to infuse on different days.

The care plan was then reviewed. A focus area:

"Is on TPN IV" was observed. Goals were: "To

ensure that 2 lumen catheter is flushed as

ordered and patent." Interventions listed were:

"Make sure dressing is changed as ordered,

make sure site is free from infection while at

facility, make sure site on left chest is dry and

intact."

The physician orders were again reviewed, there


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were no orders on the POS for dressing changes

to the catheter site.

This surveyor asked LPN #1 to accompany her to

Resident #9's room. LPN #1 showed this

surveyor the catheter insertion site on Resident

#9's left chest. LPN #1 was asked how often the

dressing was changed. She stated, "We change

them on admission and every seven days." This

surveyor asked LPN #1 how she knew when the

seven days were up. She stated, "I look at the

date on the dressing when I disconnect the TPN."

LPN #1 was asked if there were any orders on

the TAR (treatment administration record) or the

MAR (medication administration record) to

indicate dates that the dressing was changed.

LPN #1 reviewed the MAR, TAR and progress

notes and stated, "I don't see where it is

documented." LPN #1 was asked if there should

be a physician order on the record regarding the

dressing change. She stated, "Yes."

A copy of the POS was requested. When the

POS was obtained new orders had been added

which read: "IV Dressing change every 7 days

and PRN as needed for dressing coming off or

any part of occlusive seal not sealed" and "IV

Dressing change every 7 days and PRN every

day shift every 7 days for protocol change

dressing and adapters." The corporate nurse

consultant was asked where the new orders had

come from. She stated [Name of LPN #1] got

them from the physician....we should have had

them."





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F 279

SS=E

DEVELOP COMPREHENSIVE CARE PLANS

CFR(s): 483.20(d), 483.20(k)(1)

A facility must use the results of the assessment

to develop, review and revise the resident's

comprehensive plan of care.

The facility must develop a comprehensive care

plan for each resident that includes measurable

objectives and timetables to meet a resident's

medical, nursing, and mental and psychosocial

needs that are identified in the comprehensive

assessment.

The care plan must describe the services that are

to be furnished to attain or maintain the resident's

highest practicable physical, mental, and

psychosocial well-being as required under

§483.25; and any services that would otherwise

be required under §483.25 but are not provided

due to the resident's exercise of rights under

§483.10, including the right to refuse treatment

under §483.10(b)(4).


by:

F 279 4/19/16


review, the facility staff failed to develop a

comprehensive care plan for three of 24 residents

in the survey sample.

1. Resident #19 had no care plan developed

regarding antipsychotic medication.

F279

1. Resident #19�s care plan was

corrected to address antipsychotic

medication. Resident #9 no longer

resides in the facility. Resident #13�s

care plan was corrected to address

swallowing problems and the use of

therapeutic devices for eating/drinking.


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2. Resident #9 had no care plan for care of an

ileostomy.

3. Resident #13 had no care plan regarding

swallowing problems and the use of therapeutic

devices for eating/drinking.

The findings include:

1. Resident #19 had no care plan developed

regarding her use of antipsychotic medication.

Resident #19 was admitted to the facility on

11/2/13 with a re-admission on 2/21/15.

Diagnoses for Resident #19 included bipolar

disorder, dysphagia, anxiety, osteoporosis,

chronic kidney disease, tremors, irritable bowel

syndrome and hypothyroidism. The minimum

data set (MDS) dated 1/25/16 assessed Resident

#19 as cognitively intact.

Resident #19's clinical record documented a

physician's order for the antipsychotic medication

Ziprasidone 60 milligrams (mg) to be

administered twice per day for the management

of bipolar disorder. The resident's medication

administration records documented the

medication was administered as ordered. An

annual MDS assessment dated 11/2/15 listed

psychotropic drug use as a triggered concern that

required a plan of care.

Resident #19's current plan of care (revised

3/2/16) included no problems, goals and/or

interventions regarding the resident's daily use of

the antipsychotic medication Ziprasidone.

On 3/23/16 at 2:00 p.m. the registered nurse (RN

#1) responsible for care plans was interviewed

2. Nursing and dietary leadership will

review current residents that receive

antipsychotic medications, ileostomy care,

have swallowing problems, and use

therapeutic devices for eating/drinking.

Care plans will be corrected immediately

as indicated.

3. Current licensed nursing staff will be

educated regarding developing

comprehensive care plans to meet the

active care needs of the residents.

Licensed nursing staff will make daily

updates to care plans as applicable. Unit

managers or designees will review care

plans weekly X 3 months based on MDS

assessment schedule to ensure accuracy

of the care plan. Any issues will be

addressed immediately at the time of

identification.




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about Resident #19. After reviewing the care

plan RN #1 stated she did not see anything listed

about the resident's use of antipsychotic

medication. RN #1 stated problems related to the

resident's antipsychotic use were previously on

the care plan but she did not know why it was no

longer listed. RN #1 stated the problems, goals

and interventions regarding Resident 19's

antipsychotic use had been removed from the

care plan in error.

These findings were reviewed with the

administrator and director of nursing during a

meeting on 3/23/16 at 4:00 p.m.

2. Facility staff to develop a comprehensive care

plan for Resident #9's ileostomy.

Resident # 9 was originally admitted to the facility





















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A large round tube was observed coming out

from under the sheet and down the side of the

bed, the tube entered into a large rectangular

container. The tube and the container contained

brown liquid. The container was not in any type

of privacy bag and was propped up and visible

inside of a pink basin normally used for bed

baths.



surveyor to the room. This surveyor asked what

the tubing coming from under the sheet was.

LPN #1 stated, "That is her rectal tube." LPN #1

was asked why Resident #9 had a rectal tube.

She stated, "She has an ileostomy, the rectal

tube catches what doesn't come out of the

ostomy." LPN #1 asked why the resident had

both a rectal tube and an ileostomy. She stated,

"She has it [feces] coming from both places.

They put in the rectal tube to keep her from

getting any skin breakdown."

Orders were observed to "Change ostomy

appliance once a week and PRN as needed..."

and for "Ostomy care every shift for ileostomy

care. Clean around ostomy bag and empty bag

every shift and as needed." There were no

orders observed for a rectal tube on the POS.

The care plan was then reviewed. There were no

interventions on the care plan for care of the

ostomy or for a rectal tube.


Resident #9's room. LPN #1 stated, "I told you

wrong. She doesn't have a rectal tube. The tube

is from her ileostomy bag." LPN #1 showed the


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ileostomy bag to this surveyor. The ostomy bag

was open at the bottom and connected to the

tubing which then connected to the rectangular

container. The container was observed to have

been placed inside of a black privacy bag and

remained propped up in the pink basin. She

stated, "This is how she and her husband had it

hooked up at home and they wanted us to

continue it."

On 03/24/2016 at approximately 8:30 a.m., this

surveyor informed the corporate nurse consultant

that there were no interventions on the

comprehensive care plan for the care of Resident

#9's ileostomy. She stated, "It is on her orders,

but it should also be on the care plan. We will fix

it."



3. The facility staff failed to develop a CCP

(comprehensive care plan) for Resident # 13 for

the restorative dining, for a divided plate and for

dysphagia and/or any special drinking

recommendations related to the dysphagia.

Resident # 13 was readmitted to the facility on

12/06/15. Diagnoses for Resident # 13 included,

but were not limited to: TBI (traumatic brain

injury) resulting from a MVA (motor vehicle

accident), depression, spastic hemiplegia,

impulsiveness and dysphagia (difficulty

swallowing).

The most current MDS (minimum data set) dated

01/18/16, assessed the resident as having a

cognitive score of 15, indicating the resident was


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cognitively intact. The resident was also

assessed as requiring supervision, with set-up

help only for food and beverage consumption.

The resident was assessed as requiring

extensive assistance from staff for all other ADL's

(activities of daily living) .

Resident # 13 was observed eating breakfast, in

the assisted (restorative) dining room, on

03/23/16 at approximately 7:30 a.m. The resident

was sitting at a table with a food plate in front of

him and 4 small, (approximately 4 ounce) blue

cups lined up. Each cup was approximately half

full. The resident was asked what was in the 4

cups; the resident stated, "Orange juice." The

resident was then asked why he had the 4 small

cups. The resident voiced that he didn't know

why they were like that and further voiced that

one of the CNA's (certified nursing assistant) had

set it up like that for him. The resident voiced

that he did not like having 4 small cups and

voiced that he liked a big cup. The resident's

meal ticket was beside the meal tray. The meal

ticket documented: "...Restorative...Regular

Divided Plate...Cinnamon French Toast DIVIDED

PLATE...Sausage Patty DIVIDED

PLATE...Orange juice..." The resident's food

plate was had a regular, porcelain type plate; the

plate was not divided. The meal ticket did not

document anything about the resident's liquids

related to the 4 small cups.

Resident # 13's clinical record was then reviewed.

The current/active POS (physician's order set)

documented: "...Regular diet..." No physician

orders were found related to restorative dining,

the divided plate, dysphagia, and/or

recommendations related to the resident's

beverage consumption or use of 4 small cups.


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The resident's CCP (comprehensive care plan)

was then reviewed and documented: "...ADL

(activities of daily living) self-care performance

deficit r/t (related to) Musculoskeletal impairment,

contracture...EATING: The resident is able to

feed self after set up except for salads. Staff to

feed resident salad when provided (created on :

01/07/15)...Increased nutritional risk r/t history of

weight changes...Provide, serve diet as

ordered...RD to evaluate and make diet

changes..." The CCP did not address the

resident's 'restorative dining', did not address the

resident's 'divided plate' and did not address any

information related dysphagia or to any

recommendations related to the resident's

beverage consumption or the use of the 4 small

cups for drinking.

Resident # 13's therapy records were then

reviewed. A "Speech Therapy SLP (Speech

Language Pathology) Evaluation & Plan of

Treatment", dated 08/18/15 was reviewed for

Resident # 13.

The SLP documented: "...Start of Care:

8/18/15...Personal history of traumatic brain

injury...DYSPHAGIA, UNSPECIFIED...Dysphagia

unspecified...EVALUATION ONLY...electronic

signature SLP (speech therapist) # 1...I certify the

need for these medically necessary services

furnished under this plan of treatment while under

my care from 8/18/15 through 8/18/15...signature

[of] PA (physician's assistant) 8/19/15...Patient

referred...due to exacerbation of dysphagia

characterized by increased coughing and wet

voice at meals...spastic hemiplegia...patient

consuming regular texture/thin liquid diet with

minimal overt s/s (signs/symptoms) aspiration


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(e.g. coughing, wet voice)...exacerbation of

dysphagia...patient assessed with...6 oz thin

liquids via cup. Patient presents with full body

convulsions, negatively impacting patient's ability

to prepare bolus...nursing reports patient typically

impulsive and utilizes large bolus size with

occasional packing behaviors...moderate

pharyngeal dysphagia when consuming thin

liquids as evidenced by mild coughing and wet

"gurgly" voice post swallow...required moderate

cues to utilize throat clear and cough/swallow to

clear pharyngeal residue...Clinician recommends

patient receive close supervision during all meals.

Clinician also recommends patient trial Provale

cup with meals to reduce liquid bolus size and

increase safety of swallow. Clinician unable to

trial at time of evaluation due to no availability of

Provale cup. Clinician will re-educate at future

time to determine whether utilizing Provale cup

increased safety of swallow...Precautions:

Aspiration...Swallow precautions in place...Self

feeds with mild difficulty controlling cup/bolus with

utensil...Cup = Moderate; Clinical S/S Dysphagia:

Wet voice (x 3) [three times] with several

attempts to clear with cough/throat

clear/reswallow (sic); mild coughing

(x2)...behaviors impacting safety; full body

convulsions...Risk Factors: Due to the

documented physical impairments and

associated functional deficits, the patient is at risk

for: aspiration...electronic signature [3:36 p.m.]

SLP # 1.

Resident # 13's progress notes were then

reviewed from August 2015 to present.

A nursing progress note dated 08/18/15 and

timed 9:30 a.m. documented: "...At 0920 [9:20

a.m.] house keeping came to get this writer and


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reported that resident was choking and needed

assistance...assessed resident...sounds very

gurglie (sic)...trying to talk saying "help and it

sounds as if he was in water drowning as he held

his throat. (sic) Lungs assessed, not

clear...called ST [speech therapy] and made them

aware. ST stated tht (sic) it took 5 minutes for pt

[patient] to drink 1/2 cup of water. [Name of

Nurse Practitioner] was also make aware V/O

[verbal order] obtained to suction pt now and PRN

[as needed]...Resident was suctioned...ST will be

coming out to see this afternoon..."


timed 2:43 p.m. documented: "...After hearing

adventitious [abnormal] sounds in lungs this am

ST was made aware...ST worked with resident

during lunch...ST reported that this was "typical"

of this resident...suggested that resident remains

on...thin liquids but pt MUST BE SUPERVISED!

(sic)..."

At 2:10 p.m. on 03/23/16, the RD presented an

"Activity Log Report." The RD voiced that this

report documented when the divided plate was

initiated for Resident # 13, which was 04/27/13.

The RD voiced, it was initiated because the

resident shakes and has spastic movements and

that the resident should have had a divided plate

this morning.

The administrator, DON (director of nursing) and

CN (corporate nurse) # 1 and # 2 were made

aware of the above in a meeting with the survey

team on 03/23/16 at 3:50 p.m. The facility staff

was asked for any information related to the

resident's dysphagia and/or the use of the 4

small, blue cups. The facility staff agreed that all

of the above information should have been


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included in the resident's CCP.

No further information or documentation was

presented prior to the exit conference on

03/24/16.

F 280

SS=D

RIGHT TO PARTICIPATE PLANNING

CARE-REVISE CP

CFR(s): 483.20(d)(3), 483.10(k)(2)

The resident has the right, unless adjudged

incompetent or otherwise found to be

incapacitated under the laws of the State, to

participate in planning care and treatment or

changes in care and treatment.

A comprehensive care plan must be developed

within 7 days after the completion of the

comprehensive assessment; prepared by an

interdisciplinary team, that includes the attending

physician, a registered nurse with responsibility

for the resident, and other appropriate staff in

disciplines as determined by the resident's needs,

and, to the extent practicable, the participation of

the resident, the resident's family or the resident's

legal representative; and periodically reviewed

and revised by a team of qualified persons after

each assessment.


by:

F 280 4/19/16


review, the facility staff failed to review and revise

the comprehensive care plan for one of 24

residents in the survey sample. Resident #1's

care plan was not updated with interventions for

F280

1. Resident #1�s care plan was

corrected to address interventions for

injury prevention following a skin tear and

bruise.


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injury prevention following bruising and a skin tear

during a shower.



10/16/14 with diagnoses that included diabetes,

chronic kidney disease, osteoarthritis, chronic

obstructive pulmonary disease, cerebrovascular

accident (stroke), hypertension, anxiety and

insomnia. The minimum data set (MDS) dated

3/16/16 assessed Resident #1 as cognitively

intact.

Resident #1's clinical record documented a

nursing note dated 3/17/16 stating the resident

experienced a skin tear on her right arm from a

lift pad while the resident was on a shower bed.

The note documented, "CNA [certified nurses'

aide] pulled resident using her Hoyer pad for

assistance and the Hoyer pad tore her skin..."

The resident was treated for a skin tear and

bruising on her right arm.

The resident's plan of care (revised 3/18/16)

documented the resident had a skin tear on her

right elbow. Care plan goals related to the skin

tear stated, "The resident will be free from skin

tears through the review date." The care plan

included no interventions for prevention of injury

during showers or of any preventive actions

implemented concerning use of the Hoyer lift pad

with Resident #1. The only care plan intervention

listed to prevent skin tears was, "Identify potential

causative factors and eliminate/resolve when

possible."

On 3/23/16 at 9:45 a.m. the licensed practical

nurse (LPN #3) unit manager was interviewed

2. Current residents with identified skin

tears and bruises were reviewed to

ensure care plan interventions are in

place to prevent further injuries. Care

plans were corrected immediately as

indicated.

3. Licensed nursing staff were educated

by nursing leadership regarding care plan

accuracy to include interventions for injury

prevention following skin tears and

bruises. Licensed nursing staff will make

daily updates to care plans as applicable.

Unit managers or designees will review

care plans weekly X 3 months based on

MDS assessment schedule to ensure

accuracy of the care plan. Any issues will

be addressed immediately at the time of

identification.




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about any interventions implemented to prevent

skin tears from the lift pad for Resident #1. LPN

#3 stated the aides no longer used the lift pad to

reposition the resident when on the shower bed.

LPN #3 stated instead of using the pad to move

the resident they now rolled the resident with the

assistance of two people to prevent skin contact

with the edges of the lift pad. LPN #3 stated the

interventions implemented needed to be added to

the care plan.




F 281

SS=D

SERVICES PROVIDED MEET PROFESSIONAL

STANDARDS

CFR(s): 483.20(k)(3)(i)

The services provided or arranged by the facility

must meet professional standards of quality.


by:

F 281 4/19/16

Based on observation, staff interview and clinical

record review the facility staff failed to follow

professional standards of nursing practice for one

of 24 residents in the survey sample. Nurses

failed to clarify duplicate orders entered for

Resident #1's cough medication Guaifenesin. A

nurse documented duplicate doses of the

Guaifenesin were administered to Resident #1 on

3/9/16.



10/16/14 with diagnoses that included diabetes,

F281

1. Resident #1�s guaifenesin order was

clarified with the physician and the

resident currently receives the correct

dose and dose is documented accurately.

2. Current residents receiving

guaifenesin will be reviewed to ensure no

duplicate order and no duplicate dose

documented.

3. Licensed nursing staff will be

educated regarding duplicate orders,

administering medications at the correct

dose, and documenting accurately.

Medication pass observations will be


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chronic kidney disease, osteoarthritis, chronic

obstructive pulmonary disease, cerebrovascular

accident (stroke), hypertension, anxiety and

insomnia. The minimum data set (MDS) dated

3/16/16 assessed Resident #1 as cognitively

intact.

Resident #1's clinical record documented two

current physician orders for medication

Guaifenesin. The record documented a

physician's order dated 1/2/16 for Guaifenesin

Liquid 100 mg (milligrams) per 5 ml (milliliters);

give 10 ml every 4 hours as needed (prn) for

cough. The record also documented a

physician's order dated 3/8/16 for Guaifenesin ER

(extended release) tablet 600 mg to be given

every 12 hours as needed for sinus congestion.

Resident #1's medication administration record

(MAR) documented on 3/9/16 a 10 ml dose of the

liquid Guaifenesin was administered at 8:51 a.m.

and a 600 mg tablet of Guaifenesin was

administered at 8:52 a.m. There were no notes

documented regarding the duplicate doses. Both

doses were entered/signed off on the MAR by

licensed practical nurse (LPN) #6.

On 3/22/16 at 3:30 p.m. LPN #6 was interviewed

about Resident #1's duplicate orders for

Guaifenesin and the duplicate administration

documented on 3/9/16. LPN #6 stated she gave

only the 600 mg tablet of Guaifenesin to Resident

#1 on 3/9/16 and not the liquid. LPN #6 stated

she did not know why both the liquid and tablet

dose of Guaifenesin were marked as given on

3/9/16. LPN #6 stated Resident #1 takes her

medications whole. LPN #6 stated she did not

know why Resident #1 had two current orders for

as needed Guaifenesin. LPN #6 stated she saw

conducted 3x weekly X one month and

weekly X 2 months to validate no

duplicate orders and accurate

documentation of medication

administration time and doses. Any issues

will be addressed immediately at the time

of identification. MD will be notified

promptly as indicated.




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no clarification order regarding the duplicate

Guaifenesin orders.

On 3/22/16 at 4:20 p.m. accompanied by LPN #6,

Resident #1's Guaifenesin supply was observed

in the medication cart. LPN #6 stated the tablet

form of Guaifenesin was supplied in bulk form

from a bottle sent by pharmacy. LPN #6

displayed Resident #1's bottle of liquid

Guaifenesin. The liquid Guaifenesin was labeled

from the pharmacy for Resident #1 and was

marked as opened on 3/9/16. When asked about

why the bottle was opened on 3/9/16 if the liquid

Guaifenesin was not given, LPN #6 had no

response.

Resident #1's MAR documented no other doses

of Guaifenesin were administered on 3/9/16

except for the two marked by LPN #6 at 8:51 a.m.

and 8:52 a.m.

On 3/22/16 at 3:45 p.m. unit manager (LPN #3)

was interviewed about Resident #1's duplicate

orders for Guaifenesin and duplicate doses listed

as given on 3/9/16. LPN #3 stated did not know

why duplicate doses were marked given.

Concerning the duplicate orders, LPN #3 stated it

was possible that the order for the Guaifenesin

tablet on 3/8/16 was entered when the resident

already had an order for the liquid Guaifenesin.

On 3/23/16 at 9:40 a.m. the director of nursing

(DON) was interviewed about the duplicate order

and duplicate doses of Guaifenesin marked for

Resident #1. The DON stated LPN #3 said she

gave only the 600 mg tablet on 3/9/16 and not the

liquid. The DON stated she had no explanation

why the bottle of liquid Guaifenesin was opened

on 3/9/16 if not given. The DON stated, "I don't


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have any explanation for that whatsoever. I don't

know."

The facility's policy titled General Dose

Preparation and Medication Administration

(revised 1/1/13) stated, "Prior to administration of

medication, Facility staff should take all measures

required by Facility policy and Applicable Law,

including, but not limited to the following...Verify

each time a medication is administered that it is

the correct medication, at the correct dose, at the

correct route, at the correct rate, at the correct

time, for the correct resident...Confirm that the

MAR reflects the most recent medication

order...After medication

administration...Document necessary medication

administration/treatment information (e.g., when

medications are opened, when medications are

given, injection site of a medication, if

medications are refused, PRN medications,

application sight) on appropriate forms..."

The Drug Information Handbook for Nursing 13th

edition on page 12 states, "Safe administration is

grounded in the five 'Right' principles: Right

Drug, Right Dose, Right Patient, Right Route,

Right Time... Right Drug - involves checking the

drug dispensed with the written

prescription...caution must be used to determine

the exact drug prescribed... Right route should

also include knowledge about whether the

dispensed oral drug form can be changed..."

Page 586 of this reference describes Guaifenesin

as an expectorant used to help loosen phlegm

and to thin bronchial secretions making coughs

more productive. (1)

The Lippincott Manual of Nursing Practice 10th

edition on pages 16 and 17 states, "Legal claims


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most commonly made against professional

nurses include the following departures from

appropriate care: failure to assess the patient

properly or in a timely fashion, follow physician

orders, follow appropriate nursing measures,

communicate information about the patient,

adhere to facility policy or procedure, document

appropriate information in the medical record,

administer medications as ordered, and follow

physician's orders that should have been

questioned or not followed, such as orders

containing medication dosage errors." (2)




(1) Turkoski, Beatrice B., Brenda R. Lance and

Elizabeth A. Tomsik. Drug Information Handbook

for Nursing. Hudson, Ohio: Lexi-Comp, 2011.

(2) Nettina, Sandra M. Lippincott Manual of

Nursing Practice. Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins, 2014.

F 282

SS=D

SERVICES BY QUALIFIED PERSONS/PER

CARE PLAN

CFR(s): 483.20(k)(3)(ii)

The services provided or arranged by the facility

must be provided by qualified persons in

accordance with each resident's written plan of

care.


by:

F 282 4/19/16


review, the facility staff failed to implement

F282

1. Resident #2 is currently receiving


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interventions in the care plan related to pain for

one of 24 residents in the survey sample,

Resident #2 and failed to ensure staff was

knowledgeable regarding care of a catheter and

regarding the functionality of an ileostomy for one

of 24 residents in the survey sample, Resident

#9.

1. Resident #2's Care Plan (CP) was not

implemented for alternative interventions related

to pain control

2. Facility staff was not knowledgeable regarding

the type of catheter and the care needed for the

catheter, nor was facility staff knowledgeable

regarding the functionality of Resident #9's

ileostomy.


1. Resident #2 was admitted to the facility on

5/24/15 with, but not limited to, the following

diagnoses: coronary artery disease, hypertension,

chronic obstructive pulmonary disease, seizure

disorder, chronic pain, unspecified myalgia and

myositis. The most recent Minimum Data Set

(MDS) with an Assessment Reference Date

(ARD) of 5/23/16, the assessment was

incomplete during the time of the survey. The

comparison MDS with an ARD of 2/22/16, which

was a quarterly assessment was reviewed; the

resident was assessed as a nine (9) for cognitive

impairment, moderately impaired in

decision-making skills.

On 3/23/16 at approximately 8:00 a.m., Resident

#2 was observed sitting in the hallway, at the

medication cart and on a rollator; the medication

nurse who was a licensed practical nurse and will

interventions to treat pain as stated in the

care plan. Resident #9 no longer

resides at the facility.

2. Current residents receiving a

scheduled pain management regimen will

be reviewed by nursing leadership to

ensure interventions in the care plan are

being implemented to treat pain. Current

licensed nursing staff caring for residents

with ostomies and intravenous lines were

interviewed by nursing leadership to

ensure knowledge of specific care needs.

3. Current nursing staff will be educated

regarding pain management strategies to

include assessment and implementation

of interventions to treat pain. Current

licensed nursing staff will be educated

regarding identification and care of

ostomies and intravenous lines. Licensed

nurses will observe current residents for

signs of pain daily and if indicated will

provide interventions and follow up. Unit

Manager or designee will review current

residents� pain scale documentation daily

5X weekly X 3 months to determine the

need for further interventions. Current

residents will also be interviewed by

licensed nurses regarding pain with

weekly care plan schedules to determine

the residents� current pain status and

need for further pain management

regimens. Nursing leadership will validate

knowledge of current nurses caring for

residents with ostomies and intravenous

lines. Three nurses per week will be

validated X 3 months to ensure

competency. Any issues will be addressed




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be identified as LPN #2 was administering the

resident her morning medications, which

consisted of Gabapentin 600 milligrams (mg).

The resident was wearing a Fentanyl patch that

was placed on 3/21/16 on the right side of the

resident's person.

This Surveyor upon completion of the medication

observation for the resident, asked if the resident

would like to talk. Resident #2 agreed to an

interview. As this Surveyor and Resident #2

started to her room, Resident #2 stated that she

was not "feeling well" when asked. Resident #2

stated that she was in pain. This Surveyor

proceeded to ask the resident how bad her pain

was on the pain scale of 0-10; Resident #2

stated, "It's an eight (8). This Surveyor turned to

go to the medication cart to make LPN #2 aware

of the resident's complaint of pain, when the

resident's daughter in law approached this

Surveyor and stated, "If you are going in the room

to talk to my mother-in-law, you may want to find

someone else; she is not going to be bias and

she will blame everything on the nurses and staff

here at the facility (Sic)." This Surveyor asked

Resident #2 if she felt like being interviewed due

to her complaint of pain, Resident #2 stated,

"Yes, I can talk to you."

On 3/23/16 at approximately 8:30 a.m., after the

interview was completed, Resident #2 was

interviewed and asked if the pain was still

present. Resident #2 stated, "Yes, I hurt all the

time in my legs." This Surveyor left the resident's

room; the medication nurse, who was a licensed

practical nurse and will be identified as LPN #2

was standing at the medication cart. LPN #2 was

made aware that Resident #2 was complaining of

pain. LPN #2 stated, "We can't give her anything



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for pain, her family does not want her to have

anything(sic)." LPN #2 was interviewed and

asked the reasoning for the resident not being

able to have anything for pain per the family's

request, and if the resident was in pain, how was

it being managed. LPN #2 stated, "I don't know

other than her regular medicines. I wondered the

same thing, I don't know why she can't have

Tylenol for in between pain."


#2's clinical record was reviewed to include the

following:

A Pain Care Plan (CP) created on 5/23/15 and

revised on 6/11/15 was reviewed to include the

following:

"Focus: The resident has chronic pain r/t (related

to) myalgia and myositis...Goal: The resident will

verbalize adequate relief of pain or ability to cope

with incompletely relieved pain through the review

date...Interventions: Administer analgesia as

ordered...Encourage to try different pain relieving

methods i.e. positioning, relaxation therapy,

progressive relaxation, bathing, heat and cold

application, muscle stimulation, ultrasound.

Monitor/record/report to Nurse any s/sx of

non-verbal pain. Observe and report changes in

usual routine, sleep patterns, decrease in

functional abilities, decrease ROM (range of

motion), withdrawal or resistance to care..." There

were no new updates to the care plan regarding

pain.

A Physician's Progress Note dated 5/26/15 was

reviewed to include the following:

"CC: Resident seen for pain assessment S:

Resident reports pain in left leg from mid-thigh

down to foot 10/10. "My pain comes every day


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and night." Reports pain also in left buttock, and

over left ileosacral joint. Unable to give quality of

pain; when asked whether pain is sharp or dull,

replied, "both". Report's some numbness and

tingling left lower leg and foot, no numbness or

tingling right leg and foot...Also stated today, that

she has been told that she has "nerve pain", and

that she cannot be operated on as she runs the

risk of "being in a wheelchair"...A/P: chronic pain:

fentanyl patch 75 mcg (microgram) / hour,

oxymorphone 10 mg Q (every) 6 hours prn, with 8

doses requested and received since admission,

Percocet 5-325 mg Q 4 hours prn pain, with 4

doses requested and received since

admission...but despite a patchy history and pain

inconsistent with sciatica on SLR (straight leg

raise), she describes a neurogenic pain...She

seems to have a tolerance to high dose narcotics,

so will start gabapentin 100 mg BID (twice a day)

with 300 mg QHS (at bedtime /night), titrate up as

needed. Discussed with [Physician named], who

would like to schedule oxymorphone for now, so

will schedule 10 mg Q6 hours for now."

On 3/23/16 at approximately 9:47 a.m., the unit

manager, who was a licensed practical nurse and

will be identified as LPN #3 was interviewed

regarding the resident complaining of pain and

the family's request for the resident not to have

pain medication. LPN #3 stated, "I was not aware

of this; the family does not know if she is in pain

and they should not control if she can have pain

medications. I will dig around and see what I can

come up with." LPN #3 was made aware that

during the Resident Interview, Resident #2

complained of pain and stated, when asked, that

it was an eight (8) on the pain scale level of 0-10.

LPN #3 was interviewed and asked if the

Resident had any other medications to control


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breakthrough pain other than Neurontin and a

Fentanyl patch. LPN #3 stated, "I don't know, I

have to check."

On 3/23/16 at approximately 10:30 a.m., LPN #3

stated to this Surveyor, "I went to the room and

talked with [Resident named], she said her pain

was an eight (8)." When interviewed and asked

what interventions were put in place to alleviate

the resident's pain. LPN #3 stated, "She said the

Neurontin helps some and she goes to Bingo

three times a week." During the interview with

LPN #3 the director of nursing (DON) was

present and stated, in regards to the resident

receiving pain medications, "She was on

Oxycontin and the family asked that we

discontinue it because it was causing her to have

behaviors. The DON was interviewed and asked

if anything else was ordered to help control the

pain that would not cause the resident to have

behaviors but alleviate the pain. The DON stated,

"When they are admitted, we go over the orders

with [Physician named] and if he want to make

changes he does based on knowing the patient.

He discontinued the Oxycontin because the

family was against her having it and because of

her behaviors."

On 3/23/15 at approximately 10:35 a.m., the DON

and LPN #3 was made aware of the Psychology

evaluation in that it was documented that the

resident's behaviors were contributed a

medication (Risperdal) change and pain, in which

Oxycodone IR was added to manage the

resident's pain. The DON and LPN #3 was

interviewed regarding the Oxycodone and the

reason the resident was not on it as

recommended by the Psychologist. The DON

stated, "Her son did not want her to have it so he


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asked the doctor to discontinue it." When

interviewed regarding the location of other

non-pharmacological interventions that was

provided to relieve the resident's pain, the DON

stated, "It should be documented in the nursing

notes."

On 3/23/15 at approximately 1:00 p.m., Resident

#2's Pain Level Summary from May 2015 through

March 2016 was presented to this Surveyor, the

Summary indicated that the resident's pain level

for the month of February and March was as

follows:

3/19/16 (4)

3/17/16 (9)

3/16/16 (6)

3/10/16 (5)

3/6/16 (7)

3/5/16 (4)

3/4/16 (6)

2/29/16 (4)

2/20/16 (8)

2/19/16 (5)

2/18/16 (5)

2/16/16 (8)

2/15/16 (5)

2/12/16 (9)

2/11/16 (5)

2/9/16 (5)

2/8/16 (5)

2/7/16 (9)

2/6/16 (9)

2/5/16 (5)

2/4/16 (6)

2/3/16 (6)

2/2/16 (7)

2/1/16 (6)


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#2's nursing notes from February 2016 through

March 2016 was reviewed in the clinical record,

the nursing notes did not address any

pharmacological or non-pharmacological

interventions as documented on the CP to

decrease the resident's pain.

On 3/23/16 at approximately 1:20 p.m., the DON

was interviewed regarding the pain level

summary and the follow up to determine the

interventions used to manage the resident's pain.

The DON reviewed the Pain Level Summary and

stated, "If they are getting scheduled pain meds

(medicines) it (the computer) does not default to

do a follow up; it only does that if the resident is

taking prn (as needed/necessary) narcotics."

When interviewed and asked how did staff know

that the resident's pain was managed if there was

no follow up or documentation to show that

interventions were put in place, the DON stated,

"If the resident does not complain of pain

anymore, we assume that they are not in pain.

(sic)" The DON was interviewed regarding the

facility's expectations related to assessing and

then following up to ensure pain is managed. The

DON stated, "There should be a follow up. Let me

see what I can find."

On 3/23/16 at approximately 2:29 p.m., the

regional nurse consultants, who will be identified

as Administrator (Admin) #1 and #4 entered the

conference room and requested that this

Surveyor explain to them what was going on

regarding Resident #2's pain. This Surveyor

made Admin #1 and #4 aware of the resident

stating she was in pain and the pain assessment

follow up not being done to determine if the

resident's pain was relieved or that the


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interventions were being offered as CP'd. Admin

#1 stated, "The follow up documentation for pain

is not there; there is no documentation for pain I

can tell you that now."

No further information was provided during the

course of the survey regarding, care plan

interventions, pain management and following up

on pain level assessments.

2. Facility staff was not knowledgeable regarding

the type of catheter and the care needed for the

catheter, nor was facility staff knowledgeable

regarding the functionality of Resident #9's

ileostomy.

Resident #9 was originally admitted to the facility





















A large round tube was observed coming out


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from under the sheet and down the side of the

bed, the tube entered into a large rectangular

container. The tube and the container contained

brown liquid. The container was not in any type

of privacy bag and was propped up and visible

inside of a pink basin normally used for bed

baths.



surveyor to the room..This surveyor asked what

the bag was hanging at the bedside. She stated,

"Her TPN, it is through infusing, I am going to

take it down." This surveyor also asked what the

tubing coming from under the sheet was. LPN #1

stated, "That is her rectal tube." LPN #1 was

asked why Resident #9 had a rectal tube. She

stated, "She has an ileostomy, the rectal tube

catches what doesn't come out of the ostomy."

LPN #1 asked why the resident had both a rectal

tube and an ileostomy. She stated, "She has it

[feces] coming from both places. They put in the

rectal tube to keep her from getting any skin

breakdown."

The clinical record was reviewed on 03/22/2016

beginning at approximately 1:00 p.m. The POS

(Physician order sheet) contained the following

orders: "Normal Saline Flush 10 ml (milliliters)

intravenously one time per day for tunneled

catheter" and "Heparin lock flush 10 units/ml use

5 ml intravenously one time a day for tunneled

catheter." There were also orders for TPN,

different mixtures to infuse on different days.

There were no orders observed for a rectal tube

on the POS.

The care plan was then reviewed. A focus area:


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"Is on TPN IV" was observed. Goals were: "To

ensure that 2 lumen catheter is flushed as

ordered and patent." Interventions listed were:

"Make sure dressing is changed as ordered,

make sure site is free from infection while at

facility, make sure site on left chest is dry and

intact."

There were no interventions on the care plan for

care of the ostomy or for a rectal tube.


Resident #9's room. Before arriving to the room,

LPN #1 stated, "I told you wrong. She doesn't

have a rectal tube. The tube is from her

ileostomy bag." LPN #1 showed the ileostomy

bag to this surveyor. The ostomy bag was open

at the bottom and connected to the tubing which

then connected to the rectangular container. The

container was observed to have been placed

inside of a black privacy bag and remained

propped up in the pink basin. She stated, "This is

how she and her husband had it hooked up at

home and they wanted us to continue it."

LPN #1 showed this surveyor the catheter

insertion site on Resident #9's left chest. LPN #1

was asked what kind of line was in Resident #9's

chest. She stated, "It is a PICC [Peripherally

inserted central catheter]. A double lumen

catheter was observed extending from Resident

#9's upper left chest. One lumen was clamped,

the other was not. The lumen that was clamped

had a port on the end. The lumen that was not

clamped did not have a port/cap. LPN #1 was

asked to if the lumens were suppose to be

clamped. She stated, "Yes, I forgot to clamp it

when I took the TPN down this morning around

10:00." LPN #1 was asked if the port was


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suppose to have a cap on it. She stated, "Yes,

but I didn't hang the TPN, I'm not sure where the

cap is."

Two nurse consultants and the DON (director of

nursing) were at the nurse's station and was

asked about the protocol for the line, should it be

clamped, and what about caps on the ports.

The medical director was interviewed on

03/22/2016 at approximately 3:45 p.m. He

stated, "I contacted the radiologist that puts those

lines in. He said that the system is closed and

there is no back flow, it doesn't need to be

clamped or capped." The medical director was

asked what kept bacteria from sitting in the end of

the port if the port was not capped. He left the

room and returned. He stated, "I called the

radiologist back and he said as long as the

nurse's clean the port before infusing anything, it

is okay."


DON (director of nursing) on 03/22/2016 at

approximately 4:00 p.m. Information obtained

was that they catheter was a double lumen

tunneled Hohn Catheter, not a PICC as

verbalized by LPN #1.

On 03/23/2016 at approximately 9:00 a.m., the

DON came to the conference room to speak with

this surveyor. She presented information

regarding the Hohn catheter and stated, "We

changed the ports out when the resident got her

and placed these. She presented ports/adapters

as observed on the ends of Resident #9's lumen.

She stated, "The system is closed with these

adapters, it is a needleless system. The lumens

are clamped when we change these adapters


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weekly."




Concerns were voiced that the LPN caring for

Resident #9 had not known the type of central

line she was taking care of, what the care for the

line was, and had voiced that Resident #9 had a

rectal tube as well as an ileostomy.



F 309

SS=E

PROVIDE CARE/SERVICES FOR HIGHEST

WELL BEING

CFR(s): 483.25

Each resident must receive and the facility must

provide the necessary care and services to attain

or maintain the highest practicable physical,

mental, and psychosocial well-being, in

accordance with the comprehensive assessment

and plan of care.


by:

F 309 4/19/16

Based on staff interview, resident interview,

family interview and clinical record review, the

facility staff failed to assess and implement

interventions for the management of chronic pain

for one of 24 residents in the survey sample,

Resident #2.

Resident #2 was diagnosed with chronic pain

syndrome and other unspecified myalgias and

myositis. The resident was not assessed or

F309

1. Resident #2 is currently being

assessed for pain and is receiving

interventions to treat pain.

2. Current residents receiving a

scheduled pain management regimen will

be reviewed by nursing leadership to

ensure pain is being assessed and

interventions are being implemented to

treat pain.


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provided interventions to alleviate chronic pain

symptoms.



5/24/15 with, but not limited to, the following

diagnoses: coronary artery disease, hypertension,

chronic obstructive pulmonary disease , seizure

disorder, chronic pain, unspecified myalgia and

myositis. The most recent Minimum Data Set

(MDS) with an Assessment Reference Date

(ARD) of 2/22/16, which was a quarterly

assessment was reviewed. The resident was

assessed as a nine (9) for cognitive impairment,

moderately impaired in decision-making skills.


#2 was observed sitting in the hallway, at the

medication cart and on a rollator; the medication

nurse who was a licensed practical nurse and will

be identified as LPN #2, was administering the

resident her morning medications, which

consisted of Gabapentin 600 milligrams (mg).

The resident was wearing a Fentanyl patch that

was placed on 3/21/16 on the right side of the

resident's person.

This Surveyor upon completion of the medication

observation for the resident, asked if the resident

would like to talk. Resident #2 agreed to an

interview. As this Surveyor and Resident #2

started to her room, Resident #2 stated that she

was not "feeling well" when asked. Resident #2

stated that she was in pain. This Surveyor

proceeded to ask the resident how bad her pain

was on the pain scale of 0-10; Resident #2

stated, "It's an eight (8). This Surveyor turned to

go to the medication cart to make LPN #2 aware

3. Current nursing staff will be educated

regarding pain management strategies to

include assessment and implementation

of interventions to treat pain. Licensed

nurses will observe current residents for

signs of pain daily and if indicated will

provide interventions and follow up. Unit

Manager or designee will review current

residents� pain scale documentation daily

5X weekly X 3 months to determine the

need for further interventions. Current

residents will also be interviewed by

licensed nurses regarding pain with

weekly care plan schedules to determine

the residents� current pain status and

need for further pain management

regimens. Any issues will be addressed





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of the resident's complaint of pain, when the

resident's daughter-in-law approached this

Surveyor and stated, "If you are going in the room

to talk to my mother-in-law, you may want to find

someone else; she is not going to be bias and

she will blame everything on the nurses and staff

here at the facility (Sic)." This Surveyor asked

Resident #2 if she felt like being interviewed due

to her complaint of pain, Resident #2 stated,

"Yes, I can talk to you."

On 3/23/16 at approximately 8:30 a.m., after the

interview was completed, Resident #2 was

interviewed and asked if the pain was still

present. Resident #2 stated, "Yes, I hurt all the

time in my legs." This Surveyor left the resident's

room; the medication nurse,LPN #2, was

standing at the medication cart. LPN #2 was

made aware that Resident #2 was complaining of

pain. LPN #2 stated, "We can't give her anything

for pain, her family does not want her to have

anything(sic)." LPN #2 was interviewed and

asked the reasoning for the resident not being

able to have anything for pain per the family's

request, and if the resident was in pain, how was

it being managed. LPN #2 stated, "I don't know

other than her regular medicines. I wondered the

same thing, I don't know why she can't have

Tylenol for in between pain."


#2's clinical record was reviewed to include the

following:

A Psychology evaluation dated 8/10/15 was

reviewed in the clinical record to include the

following:

"8/10/15...Hospital Course: According to the


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facility she had become quite difficult to redirect

after being quarantined for several weeks...in the

context of being quarantined and also the

discontinuation of her Risperdal that her

behaviors became problematic, out of control

according to the records...Although her behaviors

may seem intentional during her stay on a

geri-psych unit, and from reports from the facility,

much of what she has been doing is not willful,

but is in the context of her decline and her

dementing illness. During her stay on the

Geri-psych we simply restarted her Risperdal at 2

mg daily. We also added a low dose of Lexapro

and continued with her Cymbalta in hopes of

managing her depression which is related to the

pain that she has in her legs and back...In

addition we are making changes with her pain

medication as she was on Neurontin 300 mg tid

(three times a day) and we have increased that to

600 mg t.i.d and changed her prn (as

needed/necessary) pain medications to

Oxycodone IR 15 mg every three hours as

needed for pain.

[Resident named] also has a Fentanyl patch

which is to be applied every 72 hours in

managing the pain as well. At the time of

discharge, [Resident named] is quite, safe,

stable...As noted above, she has really not

displayed any type of aggressive

behaviors...Ultimately the intervention that we

found successful with [Resident named] was to

restart the Risperdal that had been

discontinued...Disposition and Followup Plans:

[Resident named] is discharging to [Facility

named]. Her son who serves as her power of

attorney agrees with the disposition..."

A Pain Care Plan (CP) created on 5/23/15 and


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revised on 6/11/15 was reviewed to include the

following:

"Focus: The resident has chronic pain r/t (related

to) myalgia and myositis...Goal: The resident will

verbalize adequate relief of pain or ability to cope

with incompletely relieved pain through the review

date...Interventions: Administer analgesia as

ordered...Encourage to try different pain relieving

methods i.e. positioning, relaxation therapy,

progressive relaxation, bathing, heat and cold

application, muscle stimulation, ultrasound.

Monitor/record/report to Nurse any s/sx of

non-verbal pain. Observe and report changes in

usual routine, sleep patterns, decrease in

functional abilities, decrease ROM (range of

motion), withdrawal or resistance to care..." There

were no new updates to the care plan regarding

pain.

A Physician's Progress Note dated 5/26/15 was


"CC: Resident seen for pain assessment S:

Resident reports pain in left leg from mid-thigh

down to foot 10/10. "My pain comes every day

and night." Reports pain also in left buttock, and

over left ileosacral joint. Unable to give quality of

pain; when asked whether pain is sharp or dull,

replied, "both". Report's some numbness and

tingling left lower leg and foot, no numbness or

tingling right leg and foot...Also stated today, that

she has been told that she has "nerve pain", and

that she cannot be operated on as she runs the

risk of "being in a wheelchair"...A/P: chronic pain:

fentanyl patch 75 mcg (microgram) / hour,

oxymorphone 10 mg Q (every) 6 hours prn, with 8

doses requested and received since admission,

Percocet 5-325 mg Q 4 hours prn pain, with 4

doses requested and received since

admission...but despite a patchy history and pain


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inconsistent with sciatica on SLR (straight leg

raise), she describes a neurogenic pain...She

seems to have a tolerance to high dose narcotics,

so will start gabapentin 100 mg BID (twice a day)

with 300 mg QHS (at bedtime /night), titrate up as

needed. Discussed with [Physician named], who

would like to schedule oxymorphone for now, so

will schedule 10 mg Q6 hours for now."

On 3/23/16 at approximately 9:47 a.m., the unit

manager, who was a licensed practical nurse and

will be identified as LPN #3 was interviewed

regarding the resident complaining of pain and

the family's request for the resident not to have

pain medication. LPN #3 stated, "I was not aware

of this; the family does not know if she is in pain

and they should not control if she can have pain

medications. I will dig around and see what I can

come up with." LPN #3 was made aware that

during the Resident Interview, Resident #2

complained of pain and stated, when asked, that

it was an eight (8) on the pain scale level of 0-10.

LPN #3 was interviewed and asked if the

Resident had any other medications to control

breakthrough pain other than Neurontin and a

Fentanyl patch. LPN #3 stated, "I don't know, I

have to check."

On 3/23/16 at approximately 10:30 a.m., LPN #3

stated to this Surveyor, "I went to the room and

talked with [Resident named], she said her pain

was an eight (8)." When interviewed and asked

what interventions were put in place to alleviate

the resident's pain. LPN #3 stated, "She said the

Neurontin helps some and she goes to Bingo

three times a week." During the interview with

LPN #3 the director of nursing (DON) was

present and stated, in regards to the resident

receiving pain medications, "She was on


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Oxycontin and the family asked that we

discontinue it because it was causing her to have

behaviors. The DON was interviewed and asked

if anything else was ordered to help control the

pain that would not cause the resident to have

behaviors but alleviate the pain. The DON stated,

"When they are admitted, we go over the orders

with [Physician named] and if he want to make

changes he does based on knowing the patient.

He discontinued the Oxycontin because the

family was against her having it and because of

her behaviors."

On 3/23/15 at approximately 10:35 a.m., the DON

and LPN #3 was made aware of the Psychology

evaluation in that it was documented that the

resident's behaviors were contributed a

medication (Risperdal) change and pain, in which

Oxycodone IR was added to manage the

resident's pain. The DON and LPN #3 was

interviewed regarding the Oxycodone and the

reason the resident was not on it as

recommended by the Psychologist. The DON

stated, "Her son did not want her to have it so he

asked the doctor to discontinue it." When

interviewed regarding the location of other

nonpharmalogical interventions that was provided

to relieve the resident's pain, the DON stated, "It

should be documented in the nursing notes."


#2's Pain Level Summary from May 2015 through

March 2016 was presented to this Surveyor, the

Summary indicated that the resident's pain level

for the month of February and March was as

follows:

3/19/16 (4)

3/17/16 (9)


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3/16/16 (6)

3/10/16 (5)

3/6/16 (7)

3/5/16 (4)

3/4/16 (6)

2/29/16 (4)

2/20/16 (8)

2/19/16 (5)

2/18/16 (5)

2/16/16 (8)

2/15/16 (5)

2/12/16 (9)

2/11/16 (5)

2/9/16 (5)

2/8/16 (5)

2/7/16 (9)

2/6/16 (9)

2/5/16 (5)

2/4/16 (6)

2/3/16 (6)

2/2/16 (7)

2/1/16 (6)


#2's nursing notes from February 2016 through

March 2016 was reviewed in the clinical record,

the nursing notes did not address any

pharmalogical or nonpharmalogical interventions

as documented on the CP to decrease the

resident's pain.


was interviewed regarding the pain level

summary and the follow up to determine the

interventions used to manage the resident's pain.

The DON reviewed the Pain Level Summary and

stated, "If they are getting scheduled pain meds

(medicines) it (the computer) does not default to

do a follow up; it only does that if the resident is


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taking prn (as needed/necessary) narcotics."

When interviewed and asked how did staff know

that the resident's pain was managed if there was

no follow up or documentation to show that

interventions were put in place, the DON stated,

"If the resident does not complain of pain

anymore, we assume that they are not in pain.

(sic)" The DON was interviewed regarding the

facility's expectations related to assessing and

then following up to ensure pain is managed. The

DON stated, "There should be a follow up. Let me

see what I can find."


#2's Nursing Notes in the clinical record was


"10/14/15 7:11 a.m. Son [named] called and

stated that he does not want his mother to have

the new pill that was prescribed "Oxycontin"

because he feels its making her non functional."

"10/14/15 13:13 (1:13 p.m.) Resident's oxycontin

30 mg has been discontinued per MD (doctor).

Resident to start oxycodone 10 mg q12 hrs with

Ibuprofen. Resident also has an appointment set

up with the pain center on November 18, [Son

named] notified of change in medication orders."

"11/9/15 17:30 (5:30 p.m.) This nurse received a

telephone call from [person named] (11:35) from

the Pain Management Center. [person named]

stated that [Physician named] will not be in the

office on tomorrow and they will have to cancel

[Resident named] appt that is scheduled with him

for tomorrow. [Person named] states that they

have rescheduled her appt for December 23,

2015 at 11:00 am..."

A review of the resident's clinical record did not

evidence that the resident was sent out to the


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Pain Management Clinic on 12/23/15.


entered the conference room and stated, "[Nurse

named] talked to [Physician named] and as

stated earlier he does not want to give her

anything additional for pain. When interviewed

and asked the reasoning, the DON stated, "He

said he did not feel comfortable (Sic)." When

asked about the pain clinic consult, the DON

stated, "We tried to get her in today (3/23/16) but

they can't see her today. We asked her, the

resident, since we could not control her pain, if

she wanted to go to the hospital; she said 'No.'

The DON further stated, [Nurse named] did get

her some prn (as needed/necessary) Tylenol and

the son agreed to her having it." When

interviewed and asked the reason the resident

was not sent to the pain clinic as previously

recommended, the DON stated, "I have the

documentation from the pain clinic, when she was

first scheduled for an appointment the pain clinic

called and canceled the appointment, because

the doctor was on vacation. The next

appointment the daughter-in-law called and

canceled the appointment because the facility

was managing her, the resident's, pain and she

told them if she needed them in the future she

would call them."

On 3/23/16 at approximately 2:29 p.m., the

regional nurse consultants, who will be identified

as Administrator (Admin) #1 and #4 entered the

conference room and requested that this

Surveyor explain to them what was going on

regarding Resident #2's pain. This Surveyor

made Admin #1 and #4 aware of the resident

stating she was in pain and the pain assessment

follow up not being done to determine if the


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resident's pain was relieved. Admin #1 stated,

"The follow up documentation for pain is not

there; there is no documentation for pain I can tell

you that now."


resident's son and daughter requested to meet

with this Surveyor, a meeting was held in the

conference room in the presence of other

Surveyors with the family. The son stated that he

did not want his mother to take pain medications

because of her past addiction. The son further

stated that the resident can be very manipulative

in trying to get pain medications. The

daughter-in-law stated that the resident's

appointment was canceled because she felt the

resident was being treated for pain at the facility

and it was under control.


clinical record was thoroughly reviewed and a

diagnosis of drug addiction was not documented

in the clinical record as a diagnosis. The clinical

record did evidence that the resident, prior to

coming to the facility on 8/10/15 was treated at

another facility from May 4, 2015 through May 8,

2015 for pain control and the documentation

evidenced that the resident's pain was being

controlled.

No further information was provided during the

course of the survey regarding the resident pain

management and following up on pain level

assessments.

F 311

SS=D

TREATMENT/SERVICES TO

IMPROVE/MAINTAIN ADLS

CFR(s): 483.25(a)(2)

F 311 4/19/16


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A resident is given the appropriate treatment and

services to maintain or improve his or her abilities

specified in paragraph (a)(1) of this section.


by:

Based on observation and staff interview, the

facility staff failed to provide restorative services

per the care plan for one of 24 residents,

Resident #15.

Resident #15 was not provided restorative dining

interventions during the breakfast meal on

03/23/2016.

Findings were:


07/22/2014. Her diagnoses included but were not

limited to: Parkinson's dysphagia, type II

diabetes mellitus, hypertension, psychosis,

schizophrenia and dementia with behaviors.






cognitive status.


conducted in the west wing restorative dining




Resident # 15 was observed sitting at a table with

two other residents. She was eating her

F311


restorative dining interventions per the

care plan.

2. Current residents receiving restorative

dining services were reviewed to ensure

interventions are implemented per the

care plan.

3. Nursing staff will be educated

regarding restorative dining interventions

and implementation. Unit managers

and/or designees will review residents

receiving restorative dining daily 5X

weekly X one month then weekly X 2

months to ensure interventions are

implemented per the care plan. Any






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breakfast. The two other residents at the table did

not have trays. There were no staff members in

the room.

The corporate QI nurse came to speak with this

surveyor at approximately 8:20 a.m. She stated,

"There weren't any staff in there because the

nurse forgot to assign anyone to the dining room."

A list of all residents in the room that were

ordered restorative dining was requested.

Resident #15 was the only resident on the list.

LPN (licensed practical nurse) #8 was in charge

of the west unit and was interviewed on

03/23/2016 at approximately 9:30 a.m. regarding

staff in the dining room. She stated, "The nurse

on third shift normally does the assignment for

day shift... the nurse here last night doesn't

normally work over here... I didn't look at the

assignment and I didn't notice that no one was in

there..."

Resident #15's care plan was reviewed. The

focus area: "The resident has an ADL (activity of

daily living) self-care performance deficit r/t

[related to] limited mobility. Interventions listed

included but were not limited to: "Nursing

Rehab/restorative: Eating/swallowing Program

#1 Pt will consume at least 50 % of meals with

supervision without becoming distracted for 3

meals a day daily 6-7 days per week."




p.m. Information was requested regarding why

Resident #15 needed restorative dining services.

On 03/24/2016 at approximately 9:15 a.m. the


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DON (director of nursing) was again asked why

Resident #15 needed restorative dining services.

She stated, "She gets off track easily and she is a

wanderer...she gets up and rambles around. She

need direction...someone should have been in

there with her yesterday while she was eating."



F 323

SS=E

FREE OF ACCIDENT

HAZARDS/SUPERVISION/DEVICES

CFR(s): 483.25(h)

The facility must ensure that the resident

environment remains as free of accident hazards

as is possible; and each resident receives

adequate supervision and assistance devices to

prevent accidents.


by:

F 323 4/19/16

Based on resident interview, staff interview, and

in the course of a complaint investigation, facility

staff failed to promptly respond to resident call

lights. Facility staff failed to promptly answer

resident call lights on the East and West units of

the facility.

Findings included:

During the survey conducted 03/22/2016 through

03/24/2016 residents and staff were interviewed

by the survey team regarding timeliness of call

lights being answered. The interview responses

are documented below.

F323

1. Residents� call lights on the East and

West wing, including Resident #1 and

#16, are currently being answered

promptly.

2. Current facility residents on each unit

will be reviewed to ensure call lights are

being answered promptly. Corrections will

be made immediately as indicated.

3. Current facility staff will be educated

regarding procedures for answering call

lights promptly. Leadership staff will round

daily 5X weekly X 3 months to ensure call

lights are being answered promptly. Any


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On 3/22/16 at 2:25 p.m. Resident #1 was

interviewed about quality of life in the facility.

During this interview Resident #1 stated she

frequently experienced slow call bell response

from the aides. Resident #1 stated the call bell

response was slowest during the day shift when

the aides were busy with other residents.

Resident #1 stated many times when she

activated the call bell an aide or nurse would

come, turn the light off and say they were coming

back but never return. Resident #1 stated the

facility was short of staff especially aides and call

bells were slow because there were not enough

aides at times to respond to everyone timely.

On 03/23/2016 at 8:50 a.m. the Resident Council

President was interviewed. During this interview

he was asked about the timeliness of call lights

being answered. The Resident Council President

stated, "There often isn't enough CNA's (certified

nursing assistants) on the unit, especially if there

are only three. If they are busy in another room,

they often can't answer call lights timely."

Resident #16 was interviewed on 03/23/2016 at

9:45 a.m. Resident #16 stated, "Often times

there isn't enough staff to answer call lights.

Three aides cannot take care of sixty people.

Call lights ring on average 10-15 minutes before

they are answered. I feel that is too long.

Sometimes lights are answered, but the aide will

say I'll be back in a minute and don't ever return

until I call again. There has been two instances

where I messed myself, once in the bed, once in

the wheelchair. Both times a clean towel was

placed over the feces until I could be cleaned

up...This goes back to not enough staff."






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The DON (director of nursing) was interviewed on

2:55 p.m. regarding CNA staffing. The DON

stated, "Unit directors do daily schedule. I

oversee the master schedule. It's a rotating

schedule every two weeks. Ideally on 7-3 shift,

five CNA's on both the East and West units is

preferred, 3-11, four to five CNA's on each unit,

depending on call outs and people leaving.

People leaving usually don't even call out, they

just don't show up. Other facilities are offering

bonuses and such and people leave. Call offs

have been a problem the past few months. We

have been big time recruiting the last one and

one-half months. We have advertised different

ways...with good results. We are having

orientation weekly.

Review of the Resident Council Meeting Minutes

at approximately 4:15 p.m. revealed the following:

01/08/16 - "...Concern a/b (about) East wing

CNA...Resident's informed that all nursing

management positions are posted & (and)

accepting applications..." 02/08/16 -

"Administrative Response to Resident

Council...East wing residents state that 3rd shift

(11-7 shift) CNA (Name) frequently turns off call

light without addressing concerns of the resident

needing help..." 03/04/16 - "...Residents have

staffing concerns..."

At approximately 4:40 p.m. CNA #5 was

interviewed regarding staffing. CNA #5 stated,

"Most of the time staffing is good. Call outs

cause a problem. A wonderful day is 5-6 aides,

bad day is 3-4 aides. Decreased staffing

contributes to answering call lights slower."

CNA #6 was interviewed at approximately 4:45

p.m. CNA #6 stated, "We usually work with 3-4


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aides. Four to five aides would be good. The last

couple of months have been rough. Decreased

staff definitely contributes to untimeliness of call

lights being answered."

CNA #8 was interviewed on 03/24/2016 at

approximately 8:40 a.m. CNA #8 stated,

"Normally we have three aides. Ideally 5-6 aides

are needed. People are leaving all the time.

They say the workload is too much. Taking care

of 18-20 residents is too much. Decreased aide

staffing does affect how quickly call lights are

answered."

CNA #9 was interviewed at approximately 8:50

a.m. CNA #9 stated, "We normally work with 3-4

aides. Five to six aides would be ideal.

Decreased staff directly affects call lights being

answered. People come and go all the time."

While out on the units on 03/24/2016 a resident

on the East unit requested this surveyor to come

into their room. The resident asked what the

CNA to resident staffing ratio was in Virginia.

This surveyor explained to this resident there is

no staffing ratio in the regulations. The resident

stated, "Three aides with twenty people apiece is

too much. They can't do everything. It isn't fair to

them or us."

The Administrator and DON were informed of the

above information during a meeting with the

survey team on 03/24/2016 at approximately

10:00 a.m. No further information was received

prior to the exit conference.

F 325

SS=D

MAINTAIN NUTRITION STATUS UNLESS

UNAVOIDABLE

CFR(s): 483.25(i)

F 325 4/19/16


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Based on a resident's comprehensive

assessment, the facility must ensure that a

resident -

(1) Maintains acceptable parameters of nutritional

status, such as body weight and protein levels,

unless the resident's clinical condition

demonstrates that this is not possible; and

(2) Receives a therapeutic diet when there is a

nutritional problem.


by:

Based on observation, staff interview and clinical

record review, the facility staff failed to maintain

nutritional status for one of 24 residents, Resident

#7.

Resident #7 suffered a weight loss of 15.2

pounds or 11.9% from 12/09/2015 to 12/17/2015.

From 12/09/2015 until 03/08/2016 she lost a total

of 14.9 pounds or 11.7 percent. There were no

new interventions to address the weight loss from

12/17/2015 until 02/25/2016.

Findings were:

Resident #7 was most recently readmitted to the


diagnoses, but not limited to: Hypoglycemia,

hypertension, type II diabetes mellitus,

Alzheimer's, seizures, psychosis, and anemia.




F325

1. Resident #7�s weight is currently

stable and the goal to not experience

further significant weight loss remains

active.

2. Current residents� weights will be

reviewed to ensure significant weight loss

has been identified and interventions are

in place and documented in the plan of

care.

3. Current nursing and dietary

leadership staff will be educated by

corporate consultant regarding significant

weight loss identification and

implementation of interventions.

Interdisciplinary team will meet weekly to

review significant weight changes and

weight change trends. Residents who

trigger for subsequent weight change

trends will continue to be reviewed for

efficacy of interventions. Care plan goals

and new interventions will be implemented

as indicated by the interdisciplinary team.


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cognitive status.


conducted in the west wing restorative dining




Resident #7 was observed sitting at a table with

two other residents. Resident #7 was seated

looking across the table and out of the window.

One of the residents seated at the table was

eating breakfast. Resident #7 and another

resident did not have a tray. There were no staff

members in the room.

Resident #7's tray was served at approximately

8:00 a.m. Resident #7 was asked if she was

hungry, she stated, "I'm always hungry."

The clinical record was reviewed. Weight

recorded from December until time of survey

were:

12/09/2015: 126.9 (wheelchair)

12/17/2015: 111.7

12/29/2015: 110.0 (wheelchair)

01/06/2016: 113.7

01/13/2016: 112.5

01/20/2016: 116

01/27/2016: 114.1

02/04/2016: 115

02/17/2016: 114.5

02/24/2016: 109.3

03/02/2016: 115.6 (wheelchair)

03/08/2016: 112

03/15/2016: 113

Any issues will be addressed immediately

at the time of identification.




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03/22/2016: 112.6 (wheelchair)

Resident #7 was noted to have a significant

weight loss of 15.2 pounds or 11.9% from

12/09/2015 to 12/17/2015. From 12/09/2015 until

03/08/2016 she lost a total of 14.9 pounds or 11.7

percent.

Interventions were reviewed. According to the

facility documentation on 12/17/2015 Resident

#7's son was contacted by a nurse at the facility

to discuss Resident #7's weight loss. According

to the documentation, Resident #7's son voiced

that he was "worried that his Mother had lost so

much weight". The nurse offered interventions

that could be implemented to address the weight

loss. The son agreed to Med Pass, Chocolate

Ice Cream, chocolate milk and the resident going

to the dining room for lunch. The son felt this

would help his mother gain some of her weight

back. The RD (registered dietitian) was notified

of the conversation.

There were two RD notes for 12/17/2016. The

second note written at 12:37 p.m. contained the

following: "Sig [significant] 15.2 [pound] wt

[weight] loss X [times] one week. Observed

weight verification and chair weight verification.

Pt with hx [history] of sig wt fluctuations r/t

[related to] dx [diagnoses] High nutritional risk r/t

minimal po [by mouth] at times with rebound

intake and wt gain cycling. Pt may accept

chocolate ice cream which will be started at lunch

and dinner daily, Weekly weights ongoing for

close monitoring."

An RD noted dated 1/11/2016 contained the

following: "Pt with weight loss despite being fed

by staff. Meals in DR [dining room] w/o [without]


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consistent success. Pt can [sic] very combative

with staff trying to help or encourage her to eat.

High risk for weight changes r/t hx of sig wt

changes r/t dxs including psychosis. Following

routinely."

An RD note dated 1/21/2016 read: "3.5# weight

gain X one week. Wt gain desirable. HX of wt

gain and loss r/t dxs and behaviors. Staff to

continue to encourage intake as tolerated by pt.

Weekly wts ongoing."

On 2/17/2016 the RD made the following entry:

"Weight review Wt more stable X 2 months...med

plus TID [three times per day]...weekly weights

ongoing..."

On 2/25/2016 the RD made the following entry:

"Weekly weights reflect further weight loss. Pt

weights obtained in broda chair as pt tolerates

this better but it is not the best way to obtain an

accurate weight. Pt takes PO as desired. If

encouraged or assisted pt will attempt to bite or

strike staff per their report. Dementia with

psychosis. Pt tolerating med plus but staff does

not feel she would accept increased volume. Will

add shakes to trays to monitor response to

change."

The RD was interviewed on 03/23/2016 regarding

interventions to address Resident #7's weight

loss. The RD was asked why no further

interventions had been implemented between the

weight loss noted on 12/17/2015 and the

additional weight loss of 5.2 pounds (4.5%) in one

week on 02/24/2016. The RD stated, "I am at a

loss as to what to do with [name of resident] and

suggestions you can given me would be

appreciated." The RD continued, "Her weight


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was stable after she had the loss in December,

she fluctuates...there are weight discrepancies."

The RD was asked if the weight discrepancies

had been discussed with staff and what was the

normal protocol for someone with a sustained

weight loss. She stated, "We added the med

pass and the chocolate ice cream and chocolate

milk in December and the milk shakes in

February."

On 03/23/2016 at approximately 12:00 p.m.,

Resident #7 was observed in the west wing

restorative dining room. She had her lunch tray in

front of her. She was eating her chocolate ice

cream. She stated, "Do you know why I get

chocolate ice cream?...because the doctor thinks

I am losing weight to fast."

The RD and the corporate RD came to the

conference room to speak with this surveyor on

03/23/2016 at approximately 3:15 p.m. The RD

stated, "I spoke with the resident and her

son...the resident is very proud that she has a flat

stomach after having six kids, she is happy with

her weight and she likes the food...I spoke with

her son and he is Okay with her weight, he said

the most she has weighed is around 135

pounds...she did eat her chocolate ice cream at

lunch, and her milkshake and she ate two peanut

butter crackers while I was in the room talking to

her."

A record of Resident #7's BMI (body mass index)

was presented by the RD. The RD stated that

based on the BMI the resident was not

underweight, and that the BMI was a more

accurate indicator.



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a.m. Concerns were voiced that interventions

implemented for Resident #7's weight loss in

December 2015 were initiated by the nurse who

contacted the son. Orders for med pass

indicated the supplement was "Per the sons

request". Concerns were also voiced that the no

further interventions were implemented after

12/17/2015 until Resident #7 lost additional

weight in February 2016. The RD's comment

regarding weight discrepancies was also

discussed. The admin team was asked what

they would expect if weight discrepancies were

identified. The corporate nurse consultant stated,

"I would expect staff to weigh her the same way

and document it." The administrative team was

also asked if weight loss was only treated if the

BMI indicated the resident was underweight. Also

discussed was that the RD had not documented

that any discussion regarding the resident's

weight loss had occurred with the resident or the

son until questioned by this surveyor.

On 03/24/2016 the RD and the corporate RD

came to the conference room to speak with this

surveyor. The RD stated, "It is hard for elderly

people to regain lean body weight once they have

had a weight loss... the BMI shows that she is not

underweight." The RD was asked if interventions

were only implemented if the BMI indicated that

the resident was underweight. She stated, "No,

we look at weights but after the weight loss we try

to maintain the weight so they don't lose more."

The RD was again asked, what the facility had

done to address the weight loss after the

interventions were put into place on 12/17/2015.

She stated, "We maintained her weight so she

didn't lose more."The RD was asked why the


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information presented during survey, i.e. her BMI

is within normal limits, as well as discussion with

the resident and her son had not been

implemented and documented prior to the survey.

The corporate RD stated, "I see your

perspective." The Corporate RD was asked if

those things should have been documented. She

stated, "Yes, somewhere."



F 369

SS=E

ASSISTIVE DEVICES - EATING

EQUIPMENT/UTENSILS

CFR(s): 483.35(g)

The facility must provide special eating equipment

and utensils for residents who need them.


by:

F 369 4/19/16

Based on observation, resident interview, staff

interview and clinical record review, the facility

staff failed to provide special equipment for one

of 24 residents in the survey sample, Resident #

13.

Resident # 13 was not provided a divided plate

and/or a provale cup to assist the resident with

eating and consuming liquids at a controlled rate.

Findings include:

Resident # 13 was readmitted to the facility on

12/06/15. Diagnoses for Resident # 13 included,

but were not limited to: TBI (traumatic brain

injury) resulting from a MVA (motor vehicle

accident), depression, spastic hemiplegia,

F369

1. Resident #13 currently is receiving a

divided plate for all meals and was

reevaluated for a Provale cup for fluids

but refused. Resident is currently being

provided small cups to drink fluids.

2. Current residents will be reviewed to

ensure special equipment for eating and

drinking is provided. Corrections will be

made as necessary.

3. Nursing staff will be educated

regarding identification and use of

specialized equipment for residents that

need assistance with eating and drinking.

Nursing staff will observe meal tickets

daily to ensure special equipment is

available at the time of the meal. Any


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impulsiveness and dysphagia (difficulty

swallowing).

The most current MDS (minimum data set) dated

01/18/16, assessed the resident as having a

cognitive score of 15, indicating the resident was

cognitively intact. The resident was also

assessed as requiring supervision, with set-up

help only for food and beverage consumption.

The resident was assessed as requiring

extensive assistance from staff for all other ADL's

(activities of daily living) .

Resident # 13 was observed eating breakfast, in

the assisted (restorative) dining room, on

03/23/16 at approximately 7:30 a.m. The resident

was sitting at a table with a food plate in front of

him and 4 small (approximately 4 ounce) blue

cups lined up. Each cup was approximately half

full. The resident was asked what was in the 4

cups; the resident stated, "Orange juice." The

resident was then asked why he had the 4 small

cups. The resident voiced that he didn't know

why they were like that and further voiced that

one of the CNA's (certified nursing assistant) had

set it up like that for him. The resident voiced

that he did not like having 4 small cups and

voiced that he liked a big cup. The resident's

meal ticket was beside the meal tray. The meal

ticket documented: "...Restorative...Regular

Divided Plate...Cinnamon French Toast DIVIDED

PLATE...Sausage Patty DIVIDED

PLATE...Orange juice..." The resident's food

plate was a regular porcelain type plate; the plate

was not divided. The meal ticket did not

document anything about the resident's liquids

related to the 4 small cups.

Resident # 13's clinical record was then reviewed.


the time of identification. Unit managers

and Dietary leadership will review

residents receiving special eating and

drinking equipment weekly X 3 months to

ensure implementation. Any issues will be

addressed immediately at the time of

identification.




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The current/active POS (physician's order set)

documented: "...Regular diet..." No physician

orders were found related to the divided plate or

the resident's beverage consumption or use of 4

small cups.

The resident's CCP (comprehensive care plan)

was then reviewed and documented: "...ADL

(activities of daily living) self-care performance

deficit r/t (related to) Musculoskeletal impairment,

contracture...EATING: The resident is able to

feed self after set up except for salads. Staff to

feed resident salad when provided (created on :

01/07/15)...Increased nutritional risk r/t history of

weight changes...Provide, serve diet as

ordered...RD to evaluate and make diet

changes..." The CCP did not address the

resident's 'restorative dining', did not address the

resident's 'divided plate' and did not address any

information related to the resident's beverage

consumption or the use of the 4 small cups for

drinking.

Resident # 13's therapy records were then

reviewed. A "Speech Therapy SLP (Speech

Language Pathology) Evaluation & Plan of

Treatment", dated 08/18/15 was reviewed for

Resident # 13.

The SLP documented: "...Start of Care:

8/18/15...Personal history of traumatic brain

injury...DYSPHAGIA, UNSPECIFIED...Dysphagia

unspecified...EVALUATION ONLY...electronic

signature SLP (speech therapist) # 1...I certify the

need for these medically necessary services

furnished under this plan of treatment while under

my care from 8/18/15 through 8/18/15...signature

[of] PA (physician's assistant) 8/19/15...Patient

referred...due to exacerbation of dysphagia


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characterized by increased coughing and wet

voice at meals...spastic hemiplegia...patient

consuming regular texture/thin liquid diet with

minimal overt s/s (signs/symptoms) aspiration

(e.g. coughing, wet voice)...exacerbation of

dysphagia...patient assessed with...6 oz thin

liquids via cup. Patient presents with full body

convulsions, negatively impacting patient's ability

to prepare bolus...nursing reports patient typically

impulsive and utilizes large bolus size with

occasional packing behaviors...moderate

pharyngeal dysphagia when consuming thin

liquids as evidenced by mild coughing and wet

"gurgly" voice post swallow...required moderate

cues to utilize throat clear and cough/swallow to

clear pharyngeal residue...Clinician recommends

patient receive close supervision during all meals.

Clinician also recommends patient trial Provale

cup with meals to reduce liquid bolus size and

increase safety of swallow. Clinician unable to

trial at time of evaluation due to no availability of

Provale cup. Clinician will re-educate at future

time to determine whether utilizing Provale cup

increased safety of swallow...Precautions:

Aspiration...Swallow precautions in place...Self

feeds with mild difficulty controlling cup/bolus with

utensil...Cup = Moderate; Clinical S/S Dysphagia:

Wet voice (x 3) [three times] with several

attempts to clear with cough/throat

clear/reswallow (sic); mild coughing

(x2)...behaviors impacting safety; full body

convulsions...Risk Factors: Due to the

documented physical impairments and

associated functional deficits, the patient is at risk

for: aspiration...electronic signature [3:36 p.m.]

SLP # 1.

Resident # 13's progress notes were then

reviewed from August 2015 to present.


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timed 9:30 a.m. documented: "...At 0920 [9:20

a.m.] house keeping came to get this writer and

reported that resident was choking and needed

assistance...assessed resident...sounds very

gurglie (sic)...trying to talk saying "help and it

sounds as if he was in water drowning as he held

his throat. (sic) Lungs assessed, not

clear...called ST [speech therapy] and made them

aware. ST stated tht (sic) it took 5 minutes for pt

[patient] to drink 1/2 cup of water. [Name of

Nurse Practitioner] was also make aware V/O

[verbal order] obtained to suction pt now and PRN

[as needed]...Resident was suctioned...ST will be

coming out to see this afternoon..."


timed 2:43 p.m. documented: "...After hearing

adventitious [abnormal] sounds in lungs this am

ST was made aware...ST worked with resident

during lunch...ST reported that this was "typical"

of this resident...suggested that resident remains

on...thin liquids but pt MUST BE SUPERVISED!

(sic)...can be suctioned as needed...machine at

bedside..."

Physician progress notes were then reviewed

from August 2015 to present. No information

related to the above was found or addressed in

the physician's progress notes.

On 03/23/16 at 1:45 p.m., the RD (Registered

Dietitian) was interviewed regarding Resident #

13's meal ticket for a divided plate. The RD

viewed Resident # 13's meal ticket and was

asked, based on the ticket was the resident

supposed to have a divided plate. The RD

stated, "Yes, based on the ticket." And then


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asked, did he not have a divided plate? This

surveyor informed the RD of the breakfast

observation. The RD voiced that she would

attempt to find information regarding when the

divided plate was initiated. The RD was asked if

there has to be a physician's order for the divided

plate. The RD voiced that basically anyone could

ask to have a divided plate, if a resident can gain

benefit from it and again voiced that no

physician's order is needed.

On 03/23/16 at 2:00 p.m., SLP # 1 was

interviewed regarding the above information.

SLP # 1 voiced that the Provale cup is something

that has to be ordered [we don't just have them

here] and it measures "sip size." The SLP voiced

that she did make that recommendation and the

resident got the Provale cup. The SLP was made

aware that no information or documentation could

be located to evidence the resident received the

recommendation. The SLP voiced, yes he got it.

The SLP was asked for the evaluation and

documentation regarding the above statement.

The SLP then voiced that she didn't actually

remember if the resident was 'trialed' on the

Provale cup or not, that was a long time ago. The

SLP then voiced that she did remember the

resident telling her that he did not want the

Provale cup. The SLP was asked, when was

that. The SLP voiced that she didn't remember.

The SLP was asked, how the resident could say

he didn't want the cup if he had not tried it, the

SLP voiced that is what the resident told her. The

SLP was asked if that was documented. The

SLP stated that she did not document that

because she was not evaluating him at the time

[when the resident told her that] and she does not

document unless she is doing an evaluation and

that the resident was only evaluated by her one


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time.

At approximately 2: 05 p.m., Resident # 13 was

interviewed in his room. The resident was asked

about the breakfast observation with the 4 small,

blue cups. The resident again voiced that he did

not like those cups and pointed to a larger cup on

his BST (bedside table), that had lid and straw

and voiced that he liked the big cup. The resident

was asked if he remembered trying a Provale

cup. The resident asked, what is a provale cup?

The resident was informed that it was a special

cup that had handles, and delivered a measured

amount to allow easier swallowing and help to

prevent getting too much liquid at one time and

help prevent choking. The resident stated that

no, he had not tried one. The resident was then

asked if he would be opposed to trying it. The

resident voiced that he didn't mind to try it, but

wouldn't say that he would like it and again voiced

that he liked the larger cup and pointed to the cup

sitting on BST.

At 2:10 p.m., the RD presented an "Activity Log

Report." The RD voiced that this report

documented when the divided plate was initiated

for Resident # 13, which was 04/27/13. The RD

voiced, it was initiated because the resident

shakes and has spastic movements and that the

resident should have had a divided plate this

morning.

The administrator, DON (director of nursing) and

CN (corporate nurse) # 1 and # 2 were made

aware of the above in a meeting with the survey

team on 03/23/16 at 3:50 p.m. The staff were

asked for any information related to the above.

On 03/24/16 at approximately 9:00 a.m., CN # 1


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voiced that no physician's order could be located

to suction the resident back in August, when the

resident got choked, but there was an order for

speech therapy and voiced that it would be

presented.

At approximately 9:15 a.m. CN # 1 presented a

physician's order, which documented: "...Speech

to Eval and treat one time only for possible

aspiration..."

No further information or documentation was

presented prior to the exit conference on

03/24/16.

F 431

SS=D

DRUG RECORDS, LABEL/STORE DRUGS &

BIOLOGICALS

CFR(s): 483.60(b), (d), (e)

The facility must employ or obtain the services of

a licensed pharmacist who establishes a system

of records of receipt and disposition of all

controlled drugs in sufficient detail to enable an

accurate reconciliation; and determines that drug

records are in order and that an account of all

controlled drugs is maintained and periodically

reconciled.

Drugs and biologicals used in the facility must be

labeled in accordance with currently accepted

professional principles, and include the

appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

In accordance with State and Federal laws, the

facility must store all drugs and biologicals in

locked compartments under proper temperature

controls, and permit only authorized personnel to

F 431 4/19/16


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have access to the keys.

The facility must provide separately locked,

permanently affixed compartments for storage of

controlled drugs listed in Schedule II of the

Comprehensive Drug Abuse Prevention and

Control Act of 1976 and other drugs subject to

abuse, except when the facility uses single unit

package drug distribution systems in which the

quantity stored is minimal and a missing dose can

be readily detected.


by:

Based on observation, staff interview and facility

document review, the facility staff failed to

properly store a medication subject to abuse on

one of three nursing units. Nine vials of injectable

Lorazepam were stored with other medications in

the West unit's refrigerator and were not in the

separately locked affixed box.


On 3/23/16 at 7:50 a.m. accompanied by license

practical nurse (LPN) #2, the medication room on

the West unit was inspected. In the unit's

medication refrigerator were nine vials of

injectable Lorazepam. The vials of Lorazepam

were stored with other medications in the

refrigerator and were not in the separately affixed

lock box. LPN #2 was interviewed at this time

about the storage of the Lorazepam. LPN #2

stated Lorazepam was counted each shift and

since the Lorazepam was stored in the narcotic

box on the medication cart she thought it should

be in the mounted locked box in the refrigerator.

F431

1. Lorazepam injectable vials are

currently stored in a separately locked

affixed box inside the West wing unit

refrigerator.

2. Medication refrigerators on each unit

were inspected to ensure appropriate

storage of Schedule II injectable vials.

Each unit medication room refrigerator is

currently equipped with a permanently

affixed locked box.


educated regarding proper storage of

refrigerated Schedule II injectable vials.

Nursing leadership will observe

medication room refrigerators daily 5X

weekly X one month then weekly X 2

months to ensure proper storage of

Schedule II vials. Any issues will be

corrected immediately at the time of

identification.




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On 3/23/16 at 8:00 a.m. LPN #3 unit manager

was interviewed about the storage of the

injectable Lorazepam. LPN #3 stated there was

a separately mounted lock box in the refrigerator

and the Lorazepam was supposed to be stored in

the affixed lock box.

The facility's policy titled Storage and Expiration

of Medications, Biologicals, Syringes and Needles

(revised 1/1/13) stated, "After receiving controlled

substances and adding to inventory, Facility

should ensure that Schedule II - V controlled

substances are immediately placed into a

secured storage area (i.e., a safe, self-locked

cabinet, or locked room, in all cases in

accordance with Applicable Law."

The Drug Information Handbook for Nursing 13th

edition on pages 743 through 745 describes

Lorazepam as a benzodiazepine used for the

management of anxiety disorders or anxiety

associated with depression. This reference on

page 744 states "Use with caution in patients with

a history of drug dependence, alcoholism, or

significant personality disorders.

Benzodiazepines have been associated with

dependence and acute withdrawal symptoms on

discontinuation or reduction in dose." Page 745

of this reference states under nursing actions,

"Assess for history of addiction; long-term use

can result in dependence, abuse, or tolerance...

For inpatient use, institute safety measures...

Drug may cause physical and/or psychological

dependence." (1)





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(1) Turkoski, Beatrice B., Brenda R. Lance and

Elizabeth A. Tomsik. Drug Information Handbook

for Nursing. Hudson, Ohio: Lexi-Comp, 2011.

F 441

SS=D

INFECTION CONTROL, PREVENT SPREAD,

LINENS

CFR(s): 483.65

The facility must establish and maintain an

Infection Control Program designed to provide a

safe, sanitary and comfortable environment and

to help prevent the development and transmission

of disease and infection.

(a) Infection Control Program

The facility must establish an Infection Control

Program under which it -

(1) Investigates, controls, and prevents infections

in the facility;

(2) Decides what procedures, such as isolation,

should be applied to an individual resident; and

(3) Maintains a record of incidents and corrective

actions related to infections.

(b) Preventing Spread of Infection

(1) When the Infection Control Program

determines that a resident needs isolation to

prevent the spread of infection, the facility must

isolate the resident.

(2) The facility must prohibit employees with a

communicable disease or infected skin lesions

from direct contact with residents or their food, if

direct contact will transmit the disease.

(3) The facility must require staff to wash their

hands after each direct resident contact for which

hand washing is indicated by accepted

professional practice.

F 441 4/19/16


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(c) Linens

Personnel must handle, store, process and

transport linens so as to prevent the spread of

infection.


by:

Based on observation, staff interview and facility

document review, the facility staff failed to

perform hand hygiene during a medication pass

on the East unit. A nurse administered

medications to a resident, touching his armband,

wheelchair and the cup previously held by the

resident and then prepared medications for the

next resident in the pass without performing hand

hygiene. The nurse also directly touched two of

the resident's pills with her fingertips during the

preparation of medications.


On 3/22/16 at 3:50 p.m. a medication pass

observation was conducted with licensed

practical nurse (LPN) #4. LPN #4 prepared and

administered oral medications to the first resident

in the pass. While administering the medications

to the first resident, LPN #4 touched the

resident's armband, wheelchair and the cup

previously held by the resident when taking his

medications. On 3/22/16 at 3:55 p.m. and without

any prior hand hygiene, LPN #4 prepared

medications for Resident #19. During this

preparation LPN #4 poured two Tylenol tablets in

the bottle cap then picked them out of the cap

with her bare fingertips and placed them into the

medicine cup prior to administration to the

resident.

F441


medications during medication pass

according to appropriate infection control

practices specific to hand washing.

2. Current licensed nurses will be

observed by nursing leadership staff

during a medication pass administration to

ensure hand washing practices are being

followed. Any issues will be immediately

corrected at the time of observation.


educated regarding infection control

procedures specific to hand washing

during medication pass. Medication pass

observations will be performed 3X weekly

X one month then weekly X 2 months by

nursing leadership. Any issues will be

corrected immediately at the time of

identification.




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On 3/23/16 at 2:50 p.m. LPN #4 was interviewed

about the lack of hand hygiene between residents

during the medication pass observation and

about touching Resident #19's Tylenol tablets with

her fingers. LPN #4 stated she did not wash her

hands between the residents. LPN #4 stated,

"We are told to wash or use hand sanitizer

between residents." LPN #4 stated she took the

Tylenol tablets out of the bottle cap because they

were stuck.

The facility's policy titled Handwashing

Requirements (effective 2/1/15) stated,

"Employee will wash hands at appropriate times

to reduce the risk of transmission and acquisition

of infections...Hand hygiene can consist of

handwashing with soap and water or use of an

alcohol based hand rub..." This policy stated

situations that require hand hygiene included

before and after direct patient contact and after

handling soiled equipment or utensils. The policy

titled General Dose Preparation and Medication

Administration (revised 1/1/13) stated facility staff

should perform handwashing prior to preparing

and administering medications. This policy

documented, "Facility staff should not touch the

medication when opening a bottle or unit dose

package."





Documents

PRINTED: 03/20/2018 DEPARTMENT OF HEALTH AND HUMAN